Bowel endometriosis: Surgical customization is demanding.

Bowel endometriosis is the most common form of severe deep endometriosis. Surgery is an option in case of infertility and/or chronic pain or in the presence of a stenotic lesion. Clinical examination and preoperative imaging must provide an identity card of the lesion so that customized surgery can be proposed. The primary objective of this tailor-made surgery will always be to preserve the organ. The surgeon then has three options: shaving, discoid resection and segmental resection. The more extensive the resection, the greater the risk of severe short- and long-term complications. Surgery must therefore be adapted to the patient's specific situation and needs. Moreover, personalized care must extend beyond surgery. It must begin before the operation, preparing the patient for the operation like an athlete before a race, and continue afterwards by adapting the follow-up to the surgery performed.

Anterior Percutaneous Full-Endoscopic Transcorporeal with Single-Incision Treatment for Noncontiguous 2-Level Cervical Disc Herniation: Technical Report and Early Follow-Up.

BACKGROUND: Noncontiguous 2-level cervical disc herniation (NCT-CDH) is a common condition that often requires surgical intervention. In this study, we developed a surgical approach for the treatment of NCT-CDH using anterior percutaneous full-endoscopic single incision through the vertebral body. We provide a brief overview of its safety, efficacy, and feasibility, along with a description of our relevant surgical experience. METHODS: A retrospective study was conducted, involving 30 patients who were followed up for at least 12 months. Preoperative and postoperative visual analog scale, Japanese Orthopedic Association scores, Nurick scores, intervertebral disc height, and modified Macnab criteria were recorded. Patients underwent regular radiological evaluations throughout the follow-up period. RESULTS: Postoperative computed tomography, magnetic resonance imaging, and X-ray examinations revealed bone tunnel healing, intact drilled vertebral bodies without collapse, adequate decompression of the spinal canal, and normal cervical mobility. There was a significant improvement in postoperative visual analog scale, Japanese Orthopedic Association scores, Nurick scores, and modified Macnab criteria compared to the preoperative values (P < 0.05). CONCLUSIONS: Our study revealed that the anterior percutaneous full-endoscopic transcorporeal with single-incision treatment for NCT-CDH is a safe and feasible surgical method. Therefore, it can be considered as a viable treatment option for patients with NCT-CDH.

Stapled disc excision for the repair of intraoperative rectal injury during robotic surgery for deep infiltrating endometriosis.

INTRODUCTION: Intraoperative rectal perforation is an uncommon complication of pelvic surgery, which can be life-threatening and often leads to high morbidity and stoma formation rate. PURPOSE: No consensus has been reached regarding a standard of care for intraoperative iatrogenic pelvic injury. This article presents a technique for a stapled repair to completely resect a full-thickness low rectal perforation during robotic surgery for advanced endometriosis and avoid a high-risk colorectal anastomosis and the possible need for stoma formation. CONCLUSION: Stapled discoid excision is a novel and safe technique for the repair of intraoperative rectal injuries, showing multiple benefits compared to the standard colorectal resection with or without anastomosis.

Excision of Deep Rectovaginal Endometriosis Nodules with Large Infiltration of Both Rectum and Vagina: What Is a Reasonable Rate of Preventive Stoma? A Comparative Study.

STUDY OBJECTIVE: To compare postoperative complications and rectovaginal fistula rate in women undergoing excision of large rectovaginal endometriosis requiring concomitant excision of rectum and vagina during 2 time periods with differing policies for preventive stoma confection. DESIGN: Retrospective before-and-after comparative cohort study on data prospectively recorded in a database. Patients managed from September 2018 to March 2020 (first period) were compared with those managed from April 2020 to June 2022 (second period). SETTING: Endometriosis Institute. PATIENTS: One hundred sixty-eight patients presenting with deep endometriosis infiltrating the rectum and vagina, with lesions more than 3 cm in diameter during 2 consecutive time periods with differing policies regarding use of preventive stoma. INTERVENTIONS: Rectal disc excision or colorectal resection, concomitantly with large vaginal excision. MEASUREMENTS AND MAIN RESULTS: A total of 87 and 81 women received surgery during the first and the second period, respectively, during which the rate of preventive stoma was, respectively, 32.2% and 8.6%. Deep rectovaginal nodule characteristics were comparable. The mean height (SD) of rectal sutures after disc excision and colorectal resection were, respectively, 6.5 cm (2.3 cm) and 7.2 cm (3.8 cm). Rectovaginal fistula was recorded in 17 patients, corresponding to an overall rate of 10.1%. The rates of rectovaginal fistula in the group of patients with and without preventive stoma, regardless of the period in which surgery was performed, were 11.4% and 9.8%, respectively (p = .76). The rates of fistula recorded during the first and the second period were, respectively, 9.2% and 11.1% (p = .80), and that of overall early main complications were 31% and 29.6% (p = .84). Regression logistic model identified an independent relationship between smoking and rectovaginal fistula (adjusted odds ratio [OR] 3.9, 95% confidence interval [CI] 1.1-14) after adjustment for the period (adjusted OR 1.4, 95% CI 0.4-4.9 related to the second period), stoma confection (adjusted OR 1.8, 95% CI 0.5-7.1 related to stoma confection), robotic surgery (adjusted OR 1.7, 95% CI 0.3-10.1 related to robotic assistance), and type of rectal surgery (adjusted OR 0.4, 95% CI 0.1-1.4 related to disc excision when compared with colorectal resection). CONCLUSION: No statistically significant differences were found concerning risk of rectovaginal fistula in women with rectovaginal endometriosis requiring large rectal and vaginal excision after a decision to no longer routinely perform preventive stoma.

Factors Affecting the Postoperative Bowel Function and Recurrence of Surgery for Intestinal Deep Endometriosis.

Objective: This study aims to evaluate the factors associated with complications and long-term results in the surgical treatment of intestinal deep endometriosis and to figure out the optimized treatment measures for bowel endometriosis. Methods: A retrospective study was performed in a single center in China. Medical charts were reviewed from 61 women undergoing surgical treatment for bowel endometriosis between January 2013 and August 2019 in the Department of General Gynecology, Women's Hospital School of Medicine Zhejiang University. Multivariate regression analysis was utilized to investigate the impact of the stages of endometriosis and surgical steps (independent risk factors) on complications (and postoperative bowel dysfunction). The clinical characters, surgical procedures, postoperative treatment, complications, and recurrence rate were summarized and analyzed by using Lasso regression. Results: Surgery type was the most important independent risk factor related to postoperative abnormal defecation in intestinal deep endometriosis patients (P < 0.05, OR = 34.133). Infection is the most important independent risk factor related to both postoperative complications (OR = 96.931) and recurrences after conservative surgery (OR = 4.667). Surgery type and age were significantly related to recurrences after conservative surgery. Conclusions: We recommended conservative operation especially full-thickness disc excision to improve the quality of life of intestinal deep endometriosis patients. In addition, prevention of infection is very important to reduce the postoperative complications rate and the recurrence rate.

Surgery for deep infiltrating rectal endometriosis-Selecting the right approach.

Endometriosis involving the bowel is a form of deep infiltrating endometriosis (DIE). The endometriotic lesions can infiltrate the bowel layers mimicking a malignancy. The majority of bowel involvement happens in the colon and rectum. We report our experience in surgically managing rectal endometriosis in two patients, one via a conservative approach and the other with a more radical approach and their associated short-term and long-term outcomes are observed. In principle, surgery remains the mainstay of treatment in managing rectal DIE with adjuvant hormonal therapy. The selection of surgical approach should be based on disease factors such as the size of the lesions and extent of the disease, patient factors including fitness for surgery and expectations as well as logistics and resource limitations.

Risk of Rectovaginal Fistula in Women with Excision of Deep Endometriosis Requiring Concomitant Vaginal and Rectal Sutures, with or without Preventive Stoma: A Before-and-after Comparative Study.

STUDY OBJECTIVE: To assess whether a liberal policy of preventive stoma (LPS) reduces the rate of rectovaginal fistulas in women with excision of deep endometriosis requiring concomitant vaginal and rectal sutures in comparison with a more restrictive policy of preventive stoma (RPS) and to assess the risk factors for rectovaginal fistula. DESIGN: Retrospective before-and-after comparative study. SETTING: Two referral centers, one with an LPS and the other with an RPS. PATIENTS: A total of 363 patients with deep endometriosis infiltrating the rectum and the vagina. INTERVENTIONS: Rectal disc excision or colorectal resection concomitantly with vaginal excision. MEASUREMENTS AND MAIN RESULTS: Two hundred forty-one and 122 women received surgery at the LPS and RPS centers, respectively. The rate of preventive stomas was 71.4% at the LPS center (n = 172) and 30.3% at the RPS center (N = 37). Rectovaginal fistula was recorded in 31 cases (8.5%): nineteen women were managed at the LPS center, and 12 women underwent surgery at the RPS center. It occurred in, respectively, 9.4%, 10.8%, 10.1%, and 7% of the women managed without and with a stoma at the RPS center and of those managed without and with a stoma at the LPS center (p = .72). The height of the rectal stapled line was significantly lower in the women undergoing a stoma, particularly in those managed at the RPS center (5.4 ± 1.8 cm). Performing rectal sutures within 8 cm from the anal verge increased the risk of rectovaginal fistula more than 3-fold, independently of stoma creation, surgical procedure carried out on the rectum, size of vaginal infiltration, or associated excision of deep endometriosis involving the pelvic nerves (odds ratio 3.4; 95% confidence interval, 1.3-9.1). CONCLUSION: No statistically significant differences were found in terms of the risk of rectovaginal fistula between women with rectovaginal endometriosis managed by either an LPS or an RPS; however, these findings need to be confirmed by a randomized trial.

Recommendations for a Combined Laparoscopic and Transanal Approach in Treating Deep Endometriosis of the Lower Rectum-The Rouen Technique.

The complete excision of low rectovaginal deep endometriosis is a demanding surgery associated with an increased risk of intra- and postoperative complications, which can impact the quality of life. Given the choices of optimal surgery procedures available, we would like to emphasize that a minimally invasive approach with plasma medicine and a transanal disc excision could significantly improve surgery for deep endometriosis, avoiding the lateral thermal damage of vascular and parasympathetic fibers of roots S2-S5 in the pelvic plexus. The management of low rectal deep endometriosis is distinct from other gastrointestinal-tract endometriosis nodules. Suggestions and explanations are presented for this minimal approach. These contribute to individualized medical care for deep endometriosis. In brief, a laparoscopic transanal disc excision (LTADE; Rouen technique) was performed through a laparoscopic deep rectal dissection, combined with plasma energy shaving, and followed by a transanal disc excision of the low and mid-rectal deep endometriotic nodules, with the use of a semi-circular stapler. LTADE is indicated as the first-line surgical treatment for low and mid-rectal deep endometriotic nodule excisions, because it can preserve rectal length and innervation. This technique requires a multidisciplinary team with surgical colorectal training.

Colorectal endometriosis: ample data without definitive recommendations.

The preoperative work-up and optimal surgical approach to colorectal endometriosis is a highly studied topic lacking definitive recommendations. Synthesis of the available data can be extremely challenging for surgeons due to the heterogeneity of existing comparisons, a variety of studied surgical outcomes, and a predominant focus on operative complications. While these considerations are extremely important for surgeons performing such complex gynaecologic surgery there is still much to be desired with regards to evidence based guidelines for the preoperative assessment and surgical technique for colorectal endometriosis. Having an established guideline stating in which clinical situations endometriosis surgeons should performing rectovaginal shaving, versus discoid excision, versus segmental resection would be extremely important for all pelvic surgeons, even those operating in high-volume centres dedicated to the surgical management of complex endometriosis. This perspective highlights the shortcomings of the available data and attempts to create an algorithm surgeons can follow when performing surgery for colorectal endometriosis. This algorithm is based on our expert opinion after synthesising available data.

Lumbar disc herniation surgery: Is it worth adding interspinous spacer or instrumented fusion with regard to disc excision alone?

BACKGROUND: Discectomy is sometimes associated with recurrence of disc herniation and pain after surgery. The evidence to use an interspinous dynamic stabilization system or instrumented fusion in association with disc excision to prevent pain and re-operation remains controversial. In this study, we analyzed if adding interspinous spacer or fusion, offers advantages in relation to microdiscetomy alone. METHODS: Patients with lumbar disc herniation were divided in 3 groups; microdiscectomy alone (MD), microdiscectomy plus interspinous spacer (IS) and open discectomy plus posterior lumbar interbody fusion (PLIF). The clinical efficacy was measured using the Owestry Disability Index (ODI). Other outcome parameters including visual analogue scale for pain (VAS) back and legs, length of stay, direct in-hospital cost, 90-day complication rate, and 1-year re-operation rate were also evaluated. RESULTS: A total of 103 patients whose mean age was 39.1 (±8.5) years were included. A significant improvement of the ODI and VAS back and legs pain baseline score was detected in the 3 groups. After 1 year, no significant differences in ODI, VAS back and legs pain were found between the 3 groups. There was an increase of 169% of the total direct in- hospital cost in IS group and 287% in PLIF group, in relation to MD (p < 0.001). Length of stay was 86% higher in the IS group and 384% longer in the PLIF group compared to MD (p < 0.001). The 1 year re-operation rates were 5.6%, 10% and 16.2% (p = 0.33). Discectomy seems to be the main responsible for the clinical improvement, without the interspinous spacer or fusion adding any benefit. The addition of interspinous spacer or fusion increased direct in-hospital cost, length of stay, and did not protect against re-operation.

Rates of anastomotic leak and fistula following surgical management of bowel endometriosis: a comparison of shaving, discoid excision, and segmental resection.

Endometriosis is a complex chronic inflammatory condition that can create a multitude of bothersome painful symptoms for women. Bowel endometriosis is often misdiagnosed or overlooked leading to years of suffering for many women. The surgical management of bowel endometriosis varies based on extent of disease as well as surgeon experience. Surgical treatment for bowel endometriosis is complex and a variety of intraoperative and postoperative complications must be considered. Two significant postoperative complications for bowel endometriosis include anastomotic leak and fistula formation. There is continued debate regarding the appropriate surgical treatment for bowel endometriosis. Aggressive surgery with segmental bowel resection is being utilized more cautiously, with an increase in less aggressive shaving or disc excision techniques. Historic beliefs regarding the limitations of shaving and disc excision are being challenged, and with a reduction in morbidity these less aggressive techniques are winning favor among gynecologic surgeons. Shaving, discoid excision, and segmental bowel resection are all feasible surgical management options for bowel endometriosis. Segmental resection is associated with the highest rates of both anastomotic leak and fistula formation, while shaving is associated with the lowest.

Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess the impact of type of surgery for colorectal endometriosis-rectal shaving or discoid resection or segmental colorectal resection-on complications and surgical outcomes. DATA SOURCES: We performed a systematic review of all English- and French-language full-text articles addressing the surgical management of colorectal endometriosis, and compared the postoperative complications according to surgical technique by meta-analysis. The PubMed, Clinical Trials.gov, Cochrane Library, and Web of Science databases were searched for relevant studies published before March 27, 2020. The search strategy used the following Medical Subject Headings terms: ("bowel endometriosis" or "colorectal endometriosis") AND ("surgery for endometriosis" or "conservative management" or "radical management" or "colorectal resection" or "shaving" or "full thickness resection" or "disc excision") AND ("treatment", "outcomes", "long term results" and "complications"). METHODS OF STUDY SELECTION: Two authors conducted the literature search and independently screened abstracts for inclusion, with resolution of any difference by 3 other authors. Studies were included if data on surgical management (shaving, disc excision, and/or segmental resection) were provided and if postoperative outcomes were detailed with at least the number of complications. The risk of bias was assessed according to the Cochrane recommendations. TABULATION, INTEGRATION, AND RESULTS: Of the 168 full-text articles assessed for eligibility, 60 were included in the qualitative synthesis. Seventeen of these were included in the meta-analysis on rectovaginal fistula, 10 on anastomotic leakage, 5 on anastomotic stenosis, and 9 on voiding dysfunction <30 days. The mean complication rate according to shaving, disc excision, and segmental resection were 2.2%, 9.7%, and 9.9%, respectively. Rectal shaving was less associated with rectovaginal fistula than disc excision (odds ratio [OR] = 0.19; 95% confidence interval [CI], 0.10-0.36; p <.001; I2 = 33%) and segmental colorectal resection (OR = 0.26; 95% CI, 0.15-0.44; p <.001; I2 = 0%). No difference was found in the occurrence of rectovaginal fistula between disc excision and segmental colorectal resection (OR = 1.07; 95% CI, 0.70-1.63; p = .76; I2 = 0%). Rectal shaving was less associated with leakage than disc excision (OR = 0.22; 95% CI, 0.06-0.73; p = .01; I2 = 86%). No difference was found in the occurrence of leakage between rectal shaving and segmental colorectal resection (OR = 0.32; 95% CI, 0.10-1.01; p = .05; I2 = 71%) or between disc excision and segmental colorectal resection (OR = 0.32; 95% CI, 0.30-1.58; p = .38; I2 = 0%). Disc excision was less associated with anastomotic stenosis than segmental resection (OR = 0.15; 95% CI, 0.05-0.48; p = .001; I2 = 59%). Disc excision was associated with more voiding dysfunction <30 days than rectal shaving (OR = 12.9; 95% CI, 1.40-119.34; p = .02; I2 = 0%). No difference was found in the occurrence of voiding dysfunction <30 days between segmental resection and rectal shaving (OR = 3.05; 95% CI, 0.55-16.87; p = .20; I2 = 0%) or between segmental colorectal and discoid resections (OR = 0.99; 95% CI, 0.54-1.85; p = .99; I2 = 71%). CONCLUSION: Colorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis, and voiding dysfunction. Rectal shaving seems to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable for all patients with large bowel infiltration. Compared with segmental colorectal resection, disc excision has several advantages, including shorter operating time, shorter hospital stay, and lower risk of postoperative bowel stenosis.

Evaluation of functional outcomes after disc excision of deep endometriosis involving low and mid rectum using standardized questionnaires: a series of 80 patients.

AIM: The aim was to assess the functional outcome and quality of life in patients with low and mid rectal endometriosis who have undergone disc excision using a semicircular transanal staple device, a procedure we have named the Rouen technique. METHODS: This was a retrospective study of patients undergoing the Rouen technique between October 2009 and November 2018. Preoperative and postoperative demographic and operative data were recorded prospectively (mean ± SEM). Postoperative complications were recorded using the Clavien-Dindo classification. Rectal function and quality of life were assessed by the low anterior resection syndrome (LARS) and Bowel Endometriosis Syndrome (BENS) scores respectively at ≥6 months. RESULTS: The Rouen procedure was performed on 80 patients (29.7 ± 4.3). The mean diameter of resected specimens was 57 ± 10 mm, and the height of the rectal suture from the anal verge was 4.6 ± 1.2 cm. The Clavien-Dindo complications were Clavien-Dindo 1 (leg compression), Clavien-Dindo 2 (urinary tract infection, bladder self-catheterization) and Clavien-Dindo 3b (bowel obstruction, rectovaginal fistula, pyelic dilation, colorectal stenosis after resection). A rectovaginal fistula (Clavien-Dindo 3b) developed in nine (11.3%) patients and their stoma could be reversed after 99-162 days. The majority of patients (n = 50, 62.5%) had normal postoperative rectal function with LARS score ≤20. However, minor (LARS ≥ 21-29) and major rectal dysfunction (LARS ≥ 30) was seen in 18 (22.5%) and 12 (15%) patients respectively. Quality of life as measured using the BENS score was normal (BENS score 0-8) in 51 (63.8%) patients, slightly reduced (BENS score 9-16) in 24 (30%) patients and in only five (6.3%) was this a major issue (BENS score > 17). The development of a rectovaginal fistula was independently related to risk of major rectal dysfunction (adjusted OR 6.3, 95% CI 1.3-30.6). CONCLUSIONS: In our series of 80 patients with transmural low and mid rectal endometriosis disc excision using a semicircular staple device can result in good functional outcomes and quality of life and avoid the complexity and potential complications of a low anterior resection.

Nerve-sparing laparoscopic disc excision of deep endometriosis involving the bowel: a single-center experience on 371 consecutives cases.

BACKGROUND: Bowel endometriosis is the most common pattern of Deep Endometriosis (DE). Arising from the posterior portion of the cervix and spreading to the recto-vaginal septum, utero-sacral and parametrial ligaments could lead to a distortion of normal pelvic anatomy, causing pain and infertility. Hormonal therapy is the first-line treatment in non-symptomatic patient. Conversely, laparoscopic surgical treatment has to be considered when symptoms relief are not optimal or with signs of bowel occlusion. METHODS: Retrospective experience of consecutive series of patients who referred to a third-level referral center with suspected bowel DE and failure of multiple medical treatments. After an intraoperative evaluation of nodule size with a rectal shaving of its external portion, patients underwent radical DE eradication with concomitant disc excision in rectal nodules < 3 cm with no signs of substantial full-thickness infiltration. RESULTS: A total of 371 patients were considered eligible for analysis, with a median age of 37 years. The median operative time of was 180 min, with an estimated blood loss of 100 mL and a median diameter of removed rectal nodule of 25 mm. Early postoperative procedure-related complications were 47 cases of acute rectal bleeding (12.7%), that were managed by rectal endoscopy, 3 bowel anastomotic dehiscence (0.8%), 8 hemoperitoneum (2.2%) and 3 ureteral fistula (0.8%). 22 patients experienced postoperative hyperpyrexia (5.9%), while 17 women underwent transient bladder deficiency (4.6%). Median follow-up was 60 months with a bowel recurrence rate of 2.2%. There was an improvement of all symptoms in the immediate postoperative follow-up (p < 0.0001). Among all patients with childbearing desire, the pregnancy rate found was 42.2% and was obtained by in vitro fertilization (IVF) techniques in 32% of cases. CONCLUSIONS: Laparoscopic disc excision for bowel endometriosis is an effective surgical treatment in selected residual rectal nodules < 3.0 cm. The concomitant radical DE excision contributes to a significant improvement of symptoms with an acceptable complications' rate.

Risk of bowel fistula following surgical management of deep endometriosis of the rectosigmoid: a series of 1102 cases.

STUDY QUESTION: What are the risk factors and prevalence of bowel fistula following surgical management of deep endometriosis infiltrating the rectosigmoid and how can it be managed? SUMMARY ANSWER: In patients managed for deep endometriosis of the rectosigmoid, risk of fistula is increased by bowel opening during both segmental colorectal resection and disc excision and rectovaginal fistula repair is more challenging than for bowel leakage. WHAT IS KNOWN ALREADY: Bowel fistula is known to be a severe complication of colorectal endometriosis surgery; however, there is little available data on its prevalence in large series or on specific management. STUDY DESIGN, SIZE, DURATION: A retrospective study employing data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis (CIRENDO) from June 2009 to May 2019, in three tertiary referral centres. PARTICIPANTS/MATERIALS, SETTING, METHODS: One thousand one hundred and two patients presenting with deep endometriosis infiltrating the rectosigmoid, who were managed by shaving, disc excision or colorectal resection. The prevalence of bowel fistula was assessed, and factors related to the complication and its surgical management. MAIN RESULTS AND THE ROLE OF CHANCE: Of 1102 patients enrolled in the study, 52.5% had a past history of gynaecological surgery and 52.7% had unsuccessfully attempted to conceive for over 12 months. Digestive tract subocclusion/occlusion was recorded in 12.7%, hydronephrosis in 4.5% and baseline severe bladder dysfunction in 1.5%. An exclusive laparoscopic approach was carried out in 96.8% of patients. Rectal shaving was performed in 31.9%, disc excision in 23.1%, colorectal resection in 35.8% and combined disc excision and sigmoid colon resection in 2.9%. For various reasons, the nodule was not completely removed in 6.4%, while in 7.2% of cases complementary procedures on the ileum, caecum and right colon were required. Parametrium excision was performed in 7.8%, dissection and excision of sacral roots in 4%, and surgery for ureteral endometriosis in 11.9%. Diverting stoma was performed in 21.8%. Thirty-seven patients presented with bowel fistulae (3.4%) of whom 23 (62.2%) were found to have rectovaginal fistulae and 14 (37.8%) leakage. Logistic regression model showed rectal lumen opening to increase risk of fistula when compared with shaving, regardless of nodule size: adjusted odds ratio (95% CI) for disc excision, colorectal resection and association of disc excision + segmental resection was 6.8 (1.9-23.8), 4.8 (1.4-16.9) and 11 (2.1-58.6), respectively. Repair of 23 rectovaginal fistulae required 1, 2, 3 or 4 additional surgical procedures in 12 (52.2%), 8 (34.8%), 2 (8.7%) and 1 patient (4.3%), respectively. Repair of leakage in 14 patients required 1 procedure (stoma) in 12 cases (85.7%) and a second procedure (colorectal resection) in 2 cases (14.3%). All patients, excepted five women managed by delayed coloanal anastomosis, underwent a supplementary surgical procedure for stoma repair. The period of time required for diverting stoma following repair of rectovaginal fistulae was significantly longer than for repair of leakages (median values 10 and 5 months, respectively, P = 0.008). LIMITATIONS, REASONS FOR CAUTION: The main limits relate to the heterogeneity of techniques used in removal of rectosigmoid nodules and repairing fistulae, the lack of accurate information about the level of nodules, the small number of centres and that a majority of patients were managed by one surgeon. WIDER IMPLICATIONS OF THE FINDINGS: Deep endometriosis infiltrating the rectosigmoid can be managed laparoscopically with a relatively low risk of bowel fistula. When the type of bowel procedure can be chosen, performance of shaving instead of disc excision or colorectal resection is suggested considering the lower risk of bowel fistula. Rectovaginal fistula repair is more challenging than for bowel leakage and may require up to four additional surgical procedures. STUDY FUNDING/COMPETING INTEREST(S): CIRENDO is financed by the G4 Group (The University Hospitals of Rouen, Lille, Amiens and Caen) and the ROUENDOMETRIOSE Association. No financial support was received for this study. H.R. reports personal fees from ETHICON, Plasma Surgical, Olympus and Nordic Pharma outside the submitted work. The other authors declare no conflict of interests related to this topic.

Posterior rectal pouch after large full-thickness disc excision of deep endometriosis infiltrating the low/mid rectum and relationship with digestive functional outcome.

INTRODUCTION: The aim of our study is to describe MRI appearance of a posterior rectal pouch (PRP) for patients managed for low rectal endometriosis by large full-thickness disc excision and to assess its relationship with postoperative functional digestive symptoms. MATERIAL AND METHODS: Single center retrospective study including patients managed by low/mid rectal disc excision using a semi-circular stapler (the Rouen technique) from June 2009 to October 2016. Intraoperative findings and data provided by standardized gastrointestinal self-questionnaires (GIQLI, KESS, Wexner and Bristol), before and 1 year after the surgery, were prospectively recorded. Postoperative pelvic MRI were reviewed and PRP was assessed in three planes and its volume was estimated on a 3D T2 weighted sequence. RESULTS: Eighteen patients were included in the study. All patients had postoperative PRP while none of them presented with rectal stenosis. The mean (± SD) volume of the PRP was estimated at 66 ± 32 mL. The mean antero-posterior diameter was 56 mm ± 22 mm, mean height at 44 mm ± 15 mm and mean width at 46 mm ± 11 mm. No positive correlation between the volume of the PRP and the GIQLI questionnaire was found at one year after surgery (r = -0.24, 95%CI -0.51-0.69, p = 0.44). CONCLUSION: Large disc excision of low and mid rectum leads to a posterior rectal pouch, with no significant impact on postoperative functional digestive outcomes, but it is not followed by bowel stenosis.

[Early postoperative complications in a multidisciplinary surgical center exclusively dedicated to endometriosis: A 491-patients series]. / Complications postopératoires immédiates dans un centre chirurgical multidisciplinaire exclusivement dédié à l'endométriose : une série de 491 patientes.

OBJECTIVE: The objective of our study is to present the activity volume and postoperative complications in a center exclusively destined to endometriosis surgery. METHODS: Retrospective mono-centric study analyzing data collected prospectively in patients surgically managed for endometriosis from September 2018 to August 2019. RESULTS: Four hundred and ninety-one patients underwent surgery for endometriosis during 12 consecutive months: 268 for colorectal localizations (54.6%), 51 for endometriosis of the urinary tract (10.4%), 17 for nodules of ileum and right colon (3.5%), 43 for nodules of parametriums (8.8%), 12 for nodules of sacral roots and sciatic nerves (2.4%), 7 for diaphragmatic localizations (1.4%). Among 268 patients with colorectal endometrioses, of which 48.1% concerned the low and mid rectum, shaving was performed in 102 cases, disc excision in 96 cases and colorectal resection in 100 cases. Stoma was performed in 13.1% of the cases. Patients could have 2 different procedures for multiple colorectal nodules. One hundred and ninety-nine ovarian endometriomas were managed by plasma energy ablation in 64.8%, sclerotherapy in 11.1%, cystectomy in 13.1%, oophorectomy in 11.1%. Major postoperative complications included 12 rectovaginal fistulas, while 18 other surgical procedures were carried out for various complications. In all, 38.1% of procedures involved a general surgeon and 5.3% an urologist. CONCLUSION: The creation of centers exclusively destined to endometriosis surgery allows the multidisciplinary management of a high number of patients, with an over-representation of severe forms and rare locations of the disease, followed by satisfactory complication rates.

Recurrence after Surgery for Colorectal Endometriosis: A Systematic Review and Meta-analysis.

OBJECTIVE: The recurrence rate after colorectal surgery for endometriosis is up to 50% at 5 years. The aim of the current review and meta-analysis was to assess recurrence associated with shaving, disc excision, and segmental resection for endometriosis with colorectal involvement. DATA SOURCES: A systematic review was performed by searching the PubMed, ClinicalTrials.gov, EMBASE, Cochrane Library, and Web of Science databases for publications before February 28, 2019, using the terms "colorectal endometriosis" and "recurrence" in English. The outcome measure was histologically proven recurrence 1 year after the index surgery. METHODS OF STUDY SELECTION: Studies rated as good or fair by a study quality assessment tool were included. Two reviewers independently assessed the quality of the studies; discrepancies were discussed, and if a consensus was not reached, a third reviewer was consulted. TABULATION, INTEGRATION, AND RESULTS: Of 156 relevant published trials, 41 were systematically reviewed and 4 were included in the meta-analysis. The risk of recurrence was higher after rectal shaving than after both segmental resection (odds ratio [OR], 5.53; 95% confidence interval [CI], 2.33-13.12; I2 = 0%; p = .001) and disc excision for histologically proven recurrence (OR, 3.83; 95% CI, 1.33-11.05; I2 = 0%; p = .01). This difference was not significant when comparing disc excision with segmental resection (OR, 2.63; 95% CI, 0.8-8.65; I2 = 0%; p = .11). CONCLUSION: The current analysis shows that the risk of recurrence is lower when segmental resection or disc excision is performed than when rectal shaving is performed. This finding is important when deciding the most appropriate surgical management.

Excision versus colorectal resection in deep endometriosis infiltrating the rectum: 5-year follow-up of patients enrolled in a randomized controlled trial.

STUDY QUESTION: Is there a difference in functional outcomes and recurrence rate between conservative versus radical rectal surgery in patients with large deep endometriosis infiltrating the rectum 5 years postoperatively? SUMMARY ANSWER: No evidence was found that long-term outcomes differed when nodule excision was compared to rectal resection for deeply invasive endometriosis involving the bowel. WHAT IS KNOWN ALREADY: Functional outcomes of nodule excision and rectal resection for deeply invasive endometriosis involving the bowel are comparable 2 years after surgery. Despite numerous previously reported case series enrolling patients managed for colorectal endometriosis, long-term data remain scarce in the literature. STUDY DESIGN, SIZE, DURATION: From March 2011 to August 2013, we performed a two-arm randomized trial, enrolling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring >20 mm in length, involving at least the muscular layer in depth, and up to 50% of rectal circumference. Among them, 55 women were enrolled at one tertial referral centre in endometriosis, using a randomization list drawn up separately for this centre. Institute review board approval was obtained to continue follow-up to 10 years postoperatively. One patient requested to stop the follow-up 2 years after surgery. PARTICIPANTS/MATERIALS, SETTING, METHODS: Patients underwent either nodule excision by shaving or disc excision, or segmental resection. Randomization was performed preoperatively using sequentially numbered, opaque, sealed envelopes, and patients were informed of randomization results. The primary endpoint was the proportion of patients experiencing one of the following symptoms: constipation (1 stool/>5 consecutive days), frequent bowel movements (≥3 stools/day), anal incontinence, dysuria or bladder atony requiring self-catheterization 24 months postoperatively. Secondary endpoints were values taken from the Knowles-Eccersley-Scott-symptom questionnaire (KESS), the gastrointestinal quality of life index (GIQLI), the Wexner scale, the urinary symptom profile (USP) and the Short Form 36 Health Survey (SF36). MAIN RESULTS AND THE ROLE OF CHANCE: Fifty-five patients were enrolled. Among the 27 patients in the excision arm, two were converted to segmental resection (7.4%). One patient managed by segmental resection withdrew from the study 2 years postoperatively, presuming that associated pain of other aetiologies may have jeopardized the outcomes. The 5 year-recurrence rate for excision and resection was 3.7% versus 0% (P = 1), respectively. For excision and resection, the primary endpoint was present in 44.4% versus 60.7% of patients (P = 0.29), respectively, while 55.6% versus 53.6% of patients subjectively reported normal bowel movements (P = 1). An intention-to-treat comparison of overall KESS, GIQLI, Wexner, USP and SF36 scores did not reveal significant differences between the two arms 5 years postoperatively. Statistically significant improvement was observed shortly after surgery with no further improvement or impairment recorded 1-5 years postoperatively. During the 5-year follow-up, additional surgical procedures were performed in 25.9% versus 28.6% of patients who had undergone excision or resection (P = 0.80), respectively. LIMITATIONS, REASONS FOR CAUTION: The presumption of a 40% difference concerning postoperative functional outcomes in favour of nodule excision resulted in a lack of power for demonstration of the primary endpoint difference. WIDER IMPLICATIONS OF THE FINDINGS: Five-year follow-up data do not show statistically significant differences between conservative and radical rectal surgery for long-term functional digestive and urinary outcomes in this specific population of women with large involvement of the rectum. STUDY FUNDING/COMPETING INTEREST(S): No specific funding was received. Patient enrolment and follow-up until 2 years postoperatively was supported by a grant from the clinical research programme for hospitals in France. The authors declare no competing interests related to this study. TRIAL REGISTRATION NUMBER: This randomized study is registered with ClinicalTrials.gov, number NCT01291576. TRIAL REGISTRATION DATE: 31 January 2011. DATE OF FIRST PATIENT'S ENROLMENT: 7 March 2011.

Liposuction in Gynecomastia: An Assessment of the Suction-assisted Arthroscopic Shaver Versus Open Disc Excision Techniques.

Introduction Gynecomastia is a common problem of the male breasts, which imposes a great psychological burden on patients. It is mostly bilateral and frequently asymmetrical. Surgical management of gynecomastia has undergone significant changes over the past few decades. Currently, the predominant mode of treatment includes liposuction of the fibro-fatty tissue either alone or in combination with the removal of the glandular tissue by the open excision technique or arthroscopic shaver. This study aims to compare both techniques in terms of hematoma formation, nipple necrosis, reoperation, contour irregularities, acceptability of scarring, asymmetry, and patient satisfaction. Methods The study has been conducted at Shifa International Hospital, Islamabad, from May 2018 to September 2019. Sixty patients were included in the study. All the patients had bilateral gynecomastia and Simon's Grade II-A or II-B. The study sample was divided into two equal groups. Group A underwent liposuction combined with open disc excision while Group B underwent liposuction coupled with disc excision via suction-assisted arthroscopic shaver. Postoperatively, all the patients received follow-up for a minimum period of six months. Results In a cohort of 60 patients, the mean age was 25.76±5.38 years. There were minor differences noted in terms of hematoma formation, nipple necrosis, rates of re-operation, and contour irregularities between open disc excision and arthroscopic disc excision, respectively (p-value > 0.05). About eight patients reported asymmetry in open disc excision as compared to 10 in arthroscopic disc excision. The acceptability of scarring was reported as equal in both groups. Mean patient satisfaction was based on the visual analog scale (VAS) scale was 8.25 in both groups. No statistical difference regarding patient satisfaction was noted in both groups (p-value 0.126). Conclusion Our study concludes that arthroscopic shaver-assisted disc excision despite being a novel and minimally invasive technique does not hold superiority over conventional open disc excision for the management of gynecomastia. Furthermore, in a developing country like Pakistan, there is a lack of expertise with the procedure and a need for more training among plastic surgeons.